Inquest into the death of Shelley YOUNG
Deceased
Shelley Young
Demographics
65y, female
Date of death
2017-09-29
Finding date
2021-12-23
Cause of death
choking on a tangerine
AI-generated summary
Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine while an inpatient at Manly Hospital. She had documented choking risk and clear recommendations for supervised eating and soft diet from speech pathology. Critical failures included inadequate communication of dietary restrictions during handover from the medical ward to the mental health ward, lack of supervision during meals on the mental health unit, and placement of an unmonitored fruit bowl. Additionally, complex psychopharmacology with multiple antipsychotics, sedatives, and benzodiazepines may have contributed to altered mental state and impaired judgment. Earlier medication rationalisation, rigorous handover processes, environmental controls, and consistent supervision at mealtimes could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- inadequate supervision during meals on specialist mental health ward
- failure to communicate dysphagia and dietary restrictions during ward handover
- missing dentition and reduced mastication ability
- dysphagia associated with chronic antipsychotic use
- tardive dyskinesia affecting tongue movement
- impulsive behaviour and cognitive impairment from delirium
- unmonitored fruit bowl in common area
- complex polypharmacy with multiple antipsychotics and sedatives
- ongoing delirium at time of ward transfer
- lack of formal speech pathology review during hospital admission
Coroner's recommendations
- Ensure comprehensive communication of dietary restrictions and choking risk during ward handovers
- Implement mandatory speech pathology assessment prior to patient meals for those with identified swallowing difficulties
- Remove access to high-risk foods from patients requiring supervision
- Ensure clinical handover from medical ward to specialist mental health ward includes all relevant alerts and care planning for risk mitigation
- Implement formal admission task lists that prompt referral to speech pathology and dietician for elderly patients with mental health conditions
- Provide training to ward staff on signs of dysphagia and aspiration risk
- Ensure strict adherence to recommended diet textures and supervision requirements
- Provide a copy of these findings to Northern Beaches Hospital to ensure systemic lessons are not forgotten
Full text
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